Analysis of the methods of pharyngoesophageal reconstruction.

During the period 1972-1982, 84 pharyngoesophageal reconstructions were performed on 82 patients (10 benign lesions and 72 malignant lesions) by the Department of Otolaryngology, Mount Sinai Medical Center, New York. The overall mortality for the series was 10%, with postoperative complications developing in the majority of patients and swallowing accomplished in 61%. The most successful method of reconstruction was stomach transposition (92%), followed by cervical flap repair (68%). The least successful methods were the use of the tubed deltopectoral and pectoralis major myocutaneous flaps, colon interposition, and jejunal autografts (40%-50%). The pertinent literature is reviewed and the reported mortality, morbidity, indications, limitations, and success rates for each method of reconstruction are analyzed and compared with the present series.

Acrylic frontal cranioplasty.

The correction of contour defects of the frontal bone has been accomplished with a variety of autogenous and alloplastic materials. We report our experience in reconstructing 11 cases of congenital, traumatic, and postsurgical frontal defects with acrylic. The acrylic was cured intraoperatively within the defect in some patients, or prefabricated into a prosthesis and wired into position in others. The operative techniques for both methods of repair are detailed. The reconstruction was successful in all cases and there were no complications. The acrylic implant has been found to be well tolerated after 2-10 yr follow-up. The value of the construction of a facial moulage is stressed, especially when restoration of the orbital rim is required.

Massive necrotizing infections of the neck.

Necrotizing fascitis of the head and neck is a rare condition with only 7 cases recorded in the literature. Two cases are presented in which there was massive necrosis of the soft tissues of the neck with extension into the mediastinum. The offending organisms were a mixed bacterial flora which produced gangrene accompanied by subcutaneous emphysema. Both patients were successfully treated with a regimen of intravenous antibiotics, fasciotomy, radical debridement, and hyperbaric oxygenation (1 case). The clinical features, bacteriology, and treatment of necrotizing faciities are reviewed.

The pectoralis major myocutaneous island flap for reconstruction of the head and neck.

The anatomy, design, and blood supply of the pectoralis major myocutaneous island flap are described. This versatile, nondelayed flap has, for the most part, replaced the usual cutaneous flaps. Clinical examples of its use in head and neck reconstructive surgery are presented.

Salvage surgery for recurrent neck carcinoma after multimodality therapy.

Recurrent carcinoma of the neck after treatment by radical neck dissection and radiotherapy leads to a progressive downhill course if no further therapy is instituted. Nine such patients having fixed, recurrent neck tumors with carotid artery involvement underwent 10 salvage procedures with carotid artery resection and replacement. One patient developed a transient hemiparesis that resolved in 3 days, and in another, a permanent hemiparesis occurred. Three patients have survived longer than 12 months. One patient is free of disease at 42 months following two salvage operations. We attribute the low operative morbidity to the frequent use of the subclavian artery for proximal anastomosis and myocutaneous flaps to resurface cutaneous and mucosal defects. We conclude that salvage surgery with carotid artery replacement can be performed on selected patients who have failed combined therapy as a palliative and possibly curative measure.

Peripheral nerve sheath tumors of the paranasal sinuses.

Only 4% of peripheral nerve sheath tumors of the head and neck occur in the paranasal sinuses. The most commonly involved sinus is the maxillary antrum and the most common histologic type is benign schwannoma. Two new cases of schwannoma occurring in the sphenoid and maxillary sinuses are reported. The clinical pathologic, and radiographic features of these lesions are reviewed.

Schwannomas of the larynx: review and computed tomographic scan analysis.

Neurogenic tumors consist of schwannomas, neurofibromas, and neurosarcomas that arise from the Schwann cell of a peripheral nerve. Their occurrence in the larynx is rare, with only 115 cases having been reported. Three new cases are presented, the literature is reviewed, and the first computed tomographic (CT) scan of a benign schwannoma of the larynx is demonstrated. The diagnosis and treatment of these tumors and the CT scan analysis are discussed.

A palatal dentigerous cyst arising from a mesiodente.

Dentigerous cysts can develop from unerupted primary, permanent, or rarely supernumerary teeth. When a supernumerary tooth is in the maxilla, near the midline, it is called a mesiodente. Such a mesiodente lies in the palate and a cyst developing about this tooth can extend directly up into the nasal fossae. More commonly a dentigerous cyst arising from unerupted maxillary teeth occurs about the molar, premolar, or canine teeth and the cyst extends up into the maxillary sinus. The CT and MR findings in a rare case of a dentigerous cyst of a mesiodente are presented.

Sinonasal esthesioneuroblastoma with intracranial extension: marginal tumor cysts as a diagnostic MR finding.

PURPOSE: To determine whether the MR finding of cysts along the intracranial margin of sinonasal esthesioneuroblastomas can be considered to suggest this tumor. METHODS: MR scans of 54 patients who had sinonasal lesions with intracranial extension were examined specifically for cysts along the intracranial margins of the lesions. RESULTS: Only 3 of the 54 patients had these cysts, and all 3 of these patients had esthesioneuroblastoma. Surgical pathologic findings of one specimen showed the cyst to be marginally located within the tumor. CONCLUSION: If cysts are seen on MR along the intracranial margin of a sinonasal mass, this finding highly suggests esthesioneuroblastoma.

The varied presentations of papillary thyroid carcinoma cervical nodal disease: CT and MR findings.

PURPOSE: To review the varied presentations of metastatic cervical lymph node disease in patients with papillary thyroid carcinoma. METHODS: Thirteen cases were retrospectively collected and their clinical, imaging, surgical, and pathologic material was reviewed. In the cases reviewed there was no clinical or imaging evidence of a primary thyroid mass. RESULTS: On CT, metastatic nodes can have multiple discrete calcifications, appear as benign cysts or hyperplastic or hypervascular nodes, or have areas of high attenuation which reflect intranodal hemorrhage and/or high concentrations of thyroglobulin. On MR, the nodes can have low to intermediate T1- and high T2-weighted signal intensities or high T1- and T2-weighted signal intensities, the latter reflecting primarily a high thyroglobulin content. CONCLUSION: If any of these varied appearances of cervical lymph nodes are identified on CT or MR, especially in a woman between 20 and 40 years of age, the radiologist should suspect the diagnosis of papillary thyroid carcinoma, even in the absence of a thyroid mass.

"Benign" metastasizing meningiomas.

Less than one in 1000 meningiomas metastasizes. Although the angioblastic and hemangiopericytic tumors are believed by some authors to metastasize with a greater frequency than the other histologic forms of meningioma, most investigators believe that neither the histologic pattern, local aggressiveness, size, nor location of the tumor can be used accurately to predict which tumors will metastasize. Three new cases are presented, bringing the total reported number of metastasizing meningiomas to 113. If the angioblastic meningiomas and hemangiopericytomas are eliminated from this group, 69 reported cases of "benign" metastasizing meningioma remain.

Rare presentations of ordinary lipomas of the head and neck: a review.

The ordinary lipoma is the most common neoplasm of mesenchymal origin. Only 13% of them arise in the head and neck region and most of these occur subcutaneously in the posterior neck. Rarely, they can develop in the anterior neck, infratemporal fossa, and in or around the oral cavity, pharynx, larynx, and parotid gland. Clinically, they can be confused with other benign lesions; however, CT allows a specific diagnosis to be made in virtually all cases. This article reviews the CT appearance and differential diagnoses of lipomas in these rare locations and discusses the rare infiltrating lipoma and the relationship between parotid lipomatosis and sialosis.

Metastatic hypernephroma to the head and neck.

Eight cases of metastatic hypernephroma to the head and neck are presented with CT documentation. Hypernephroma is the third most common infraclavicular tumor to metastasize to the head and neck. Such metastases occur in about 15% of patients with this neoplasm, and nearly 8% of patients with this tumor present with disease in the head and neck region. These metastases are usually vascular and may either clinically precede the diagnosis of the renal primary tumor or may occur many years after apparently successful surgery of the primary tumor. These unusual patterns of behavior are reviewed. One of the cases presented here is the first reported incidence of cervical lymph node metastasis with hemorrhage to be documented by CT, thus adding this entity to the list of imaging differential diagnoses of cystic-appearing neck masses.

Ombudsman Rounds on the otolaryngology service.

An attempt to enhance psychiatric teaching on the Otolaryngology Service was undertaken by employing the vehicle of Ombudsman Rounds. The structure of these rounds is dictated by its major goal of maximizing the relationship of the surgeon and liaison psychiatrist as coteachers among the staff of the ENT surgical unit. Surgical residents, surgical clerks, nurses, and the social worker meet with the Chairman of the ENT Department and the liaison psychiatrist in a scheduled weekly conference, which addresses both staff and patient needs on the in-patient surgical service. Through patient interviews, multidiscipline staff presentations, chief of service surgical and prognostic summaries, and liaison psychiatrists' formulations, group discussions are undertaken. Through such an experience the staff become aware of the patient's feelings and understandings about their illness and care. The goal of Ombudsman Rounds is to enhance patient care, advance psychiatric knowledge of the multidiscipline staff, and provide an ongoing vehicle to change attitudes so that they incorporate a biopsychosocial approach to patient management on the ENT Service.

Psychiatric aspects of head and neck surgery. Part II: Body image and psychiatric intervention.

Surgery of the head and neck leads to profound changes of body image, including disfigurement and difficulties with verbalization. The psychologic importance of alterations in these areas will be discussed as well as their effect on the conduct of psychiatric treatment. Psychiatric intervention in this population demands an active approach and special preparation for the therapeutic encounter is necessary.

Psychiatric aspects of head and neck surgery. Part I: New surgical techniques and psychiatric consequences.

Individuals who undergo head and neck surgery experience extreme stressors that go beyond those which occur with the usual surgical patient. This paper will review the literature and discuss the psychiatric consequences of otolaryngeal surgery. In addition, new head and neck surgical techniques, which offer special challenges to the patient as well as to the psychiatric consultant, will be examined. Tracheostomy, which occurs as a result of head and neck surgery, is of particular importance with regard to postoperative adaptation and is a significant complication that must be reckoned with.

Psychiatric consultation on an otolaryngology liaison service.

Otolaryngology patients (especially those with tracheostomies) present a significant challenge to psychiatrists from both a diagnostic and therapeutic standpoint. To date, no study has been made of psychiatric disorders among this important group of patients. At the Mount Sinai Medical Center, a liaison psychiatrist has been involved with a specialized otolaryngology cluster unit since 1979. Using a 384-item computerized database protocol developed at Mount Sinai, data on 139 otolaryngology patients were recorded and compared with 1662 "Other" inpatient psychiatric consultations on the medical and surgical services during 1980-1987. The otolaryngology patients as a group were more likely to be male (p = 0.011), married (p = 0.001) and employed (p less than 0.001). Cancer was the most common medical disorder, and the average level of stress as reported on DSM-III's Axis IV (5.1, severe) was significantly greater (p less than 0.0001) than that for the "Other." The most common psychiatric response was adjustment disorder (36%). The length of stay of those ENT patients seen in psychiatric consultation was 26.4 days, in contrast to 11.1 days for all ENT patients. However, the length of stay of those patients on ENT receiving a psychiatric consultation was not different from the "Other" psychiatric consultation cohort (26.3 days). Despite the higher level of stress, the incidence of significant psychiatric morbidity was lower for the ENT cohort. The primary effect of the liaison psychiatrist was to lower the threshold for case identification that enhanced the referral rate on the ENT unit.

Defining the psychiatric role in spastic dysphonia.

The authors evaluated 11 surgically-treated patients with spastic dysphonia, a phonation disorder of unclear etiology. The results indicate that the illness does not appear to be a somatoform disorder, but that stress may play a role in its expression, and that there may be secondary depression and anxiety. The experience of spastic dysphonics suggests that psychiatric treatments may be inappropriately applied to an illness without clear organic etiology, whereas, conversely, a proper psychiatric role may be rejected when effective medical or surgical treatment is available. The authors recommend that psychiatrists evaluating patients with illnesses of unclear etiology should be cautious in making a primary psychiatric diagnosis unless DSM-III criteria are met.

Management of early vocal cord carcinoma.

Endoscopic stripping or laser therapy are the primary modalities for patients with premalignant vocal cord lesions and patients with T1 carcinomas of the mid-portion of the vocal cord. Partial laryngectomy is advocated for patients whose resection margins are positive following laser cordectomy, or where tumor extends to the arytenoid, anterior commissure, opposite vocal cord or subglottis. Radiotherapy is reserved for patients with tumors involving the interarytenoid region, professional voice patients, or patients unfit for general anesthesia.

Staged repair of cervical tracheoesophageal fistulae.

Acquired, nonmalignant tracheoesophageal (TE) fistulae are most often iatrogenic or trauma induced. When a cervical TE fistula is complicated by tracheal stenosis or malacia, a single-stage repair of the fistula and tracheal defect is usually advocated. Complications of this single-stage repair, which occur in 25% to 50% of patients, are secondary to either excess tension at the tracheal anastomosis or the presence of inflammation at the time of tracheal anastomosis. Complications include recurrent tracheal stenosis, pneumonia, or a recurrent TE fistula. This report describes the senior author's techniques of reconstructing the trachea when tracheal stenosis complicates a TE fistula. These techniques are illustrated in two case reports of patients with postintubation TE fistulae. Current methods of tracheal reconstruction in this setting are reviewed. The incidence of postoperative complications may decrease if tracheal reconstruction is delayed until the fistula is successfully closed.